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Topic: Payment for non par Physician (Read 3217 times)

I need advise on this please: If Physician is non par with MCO plan then can we bill to Medicaid after MCO plan denies the claim for auth/non par provider? If not then how the Physician can get paid if patient is seen?

Your best option is to contact Your state Medicaid, but basically if you saw the patient and knew they had Medicaid (primary or secondary it doesn't matter) you are most likely out of luck with this if your provider is not a Medicaid provider.

The physician is non par with the MCO but par with Medicaid correct? So the MCO is not paying and you want to bill it to Medicaid. Sriram_sub is correct that you need to check with Maryland but I believe you can bill it to them as long as you indicate why the primary (MCO) didn't pay. If you submit on paper, then include the EOB. If you submit electronically, indicate the appropriate reason for non payment (provider not par). Then they will decide whether or not they will cover the services.

I bill for a specialist provider who sees many MCO plan patients who also have Medicaid(of Pennsylvania) as a secondary. The MCO will pay their part, then the rest is a contractual adjustment, and there is no balance to bill Medicaid at that point. But, for MCO patients he sees where he is not contracted with the MCO/no auth is obtained, they are always self-pay, because Medicaid(at least in Pennsylvania) will not fork over a dime when the MCO denies the claim. That is part of being in an MCO plan...you have to see a provider in that plan, and need an auth, depending.

So for your provider, if he is not in the MCO, he has two choices...1. Don't see the patient, have them see a provider in the MCO 2. Make it a self-pay visit.

I bill for several state's Medicaid plans and I do not and cannot bill for any physician or facility who is not setup and/or contracted with the specific state's Medicaid plan. So I would say no - no out of network for state Medicaid.